Provider Demographics
NPI:1245256171
Name:RICHARDSON, ATHENA LYNETTE (MD)
Entity type:Individual
Prefix:
First Name:ATHENA
Middle Name:LYNETTE
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ATHENA
Other - Middle Name:L
Other - Last Name:PENNINGTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4033 TAMPA RD
Mailing Address - Street 2:STE. 101
Mailing Address - City:OLDSMAR
Mailing Address - State:FL
Mailing Address - Zip Code:34677-3224
Mailing Address - Country:US
Mailing Address - Phone:813-854-2003
Mailing Address - Fax:813-855-2367
Practice Address - Street 1:6671 13TH AVE N
Practice Address - Street 2:STE. 1-D
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-5417
Practice Address - Country:US
Practice Address - Phone:727-381-1147
Practice Address - Fax:727-345-2489
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME71020208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL251771000Medicaid